On Old Olympus Towering Top*Chef CMS did stir his potRelatedness, he was heard to say,Must now begin and end the dayThe hospice doc, with pen in handWith the IDG must traverse the landOf diagnosis, prognosis, services and medsArmed with data, history,Collaboration and regsAnd tell us which of these cannot be saidTo be a strand in the patient’s thread

Dear doctor, please do not despairBecause you most certainly do careAnd through discussion, deliberationDetermination and grit The salient points will surely hitDocumenting well each six month storyWith details as rich as any cacciatore

Traversing this path, a trail you blazeThat will shine a light and dispel the hazeUnus pro omnibus, omnes pro uno**From patient to staff, from Miami to JuneauA clear, coherent tale emergesThat will stand the test of regulatory surges

Take heart, therefore, and do not fearBe bold and write so all will hearFor CMS has given you the powerTo determine the diagnosis/prognosis of the hourSo lead out, as you have been trained to doBidding confusion, stress and chaos adieu

May I be the first to acknowledge that I am certainly not a poet! Let me also be clear that this is written with the utmost of respect for the sacred responsibility that we elect in accepting the privilege of caring for those at the end of their lives. However, in the stressful times in which we are living, with increasing regulatory and public scrutiny, burdensome processes (e.g., The Hospice Item Set, CR 8358, etc.),and unclear guidance (e.g., Medicare Part D), my hope is that a small dose of humor might help in palliating some of the symptoms of confusion, frustration and disempowerment. And so yes, this blog post is ‘related’!

Heather Wilson, in her March blog on “Hospice and Part D,” thoroughly covered the ins and outs of the 2014 Final Guidance on Part D requirements, relatedness and the recommended prior authorization process. What this post attempts to do is highlight the physician role in this process.

I have always loved words and like to look at healthcare delivery through what I call the “4 Cs: Communication, Coordination, Collaboration and Continuum of Care.” It’s now time to move down the alphabet chain and I propose that we look at best practices for physician involvement in this arena through the lens of the “Four Ds: Discussion, Deliberation, Determination and Documentation.”

To recap the regulatory guidance as it pertains to the hospice physician/medical director:

Hospices are responsible for all care of the patient related to the terminal prognosis and its related conditions

Unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services would be considered related

It is also the responsibility of the hospice physician to document why a patient’s medical need(s) would be unrelated to the terminal prognosis

Determination of what is related versus unrelated to the terminal prognosis remains within the clinical expertise and judgment of the hospice medical director in collaboration with the interdisciplinary group (IDG) (48 FR 56010- 56011)

Discussion

Ensure that the admission team is able to give a report to the admitting/certifying physician that includes all available data necessary for determination of eligibility, choosing the hospice-qualifying diagnosis and making relatedness/unrelatedness decisions

Encourage the hospice physician to collaborate with the referring physician or the patient’s primary physician, as this collaboration can be a rich source of information impacting clinical decision-making. These conversations often reveal data not found in the patient’s clinical record or previously shared with the admission team

Deliberation

Collaboration is essential -- whether that be with the admission nurse/team and/or the IDG

To facilitate this stage, the hospice physician needs access to all the supporting documentation of the patient’s history to make the required determinations

Ensure that there are processes in place to expeditiously procure clinical records (including inpatient hospitalizations, diagnostic reports, laboratory reports, etc.) from the primary care/referring physician, or specialist consultations, when appropriate

Determination

The hospice physician must determine the hospice-qualifying diagnosis and then which additional diagnoses (comorbidities and/or secondary conditions) are related to the terminal prognosis and which are not

Coverage decisions are not always analogous to relatedness; one must also factor in the patient’s goals of care, the time to benefit for therapies, risk/benefits of therapies, etc.

Clinical pharmacists are a valuable resource in the determination process of which medications are related/not related to the patient’s terminal prognosis

Documentation

The hospice physician must document in the clinical record all diagnoses, comorbidities, secondary conditions, therapies and medications that are determined to be unrelated to the terminal prognosis

This documentation needs to be clearly identifiable in the record

The hospice physician should complete this process at admission; with reassessment resulting in additions/changes in diagnoses; with changes in the patient’s condition, plan of care, level of care, or place of care; and at recertification

Establish a protocol for the location of documentation in each clinical record to ensure uniformity and enable quick access for clinical and auditing purposes

The hospice physician should document any communication s/he has regarding coverage determinations with patients/families, hospice team members, pharmacists, other physicians, and Part D sponsors

If there are medications/therapies that are determined to be unrelated to the terminal prognosis, the hospice physician must document the reason for the unrelated determination and communicate it to the Part D sponsor

The determination of relatedness is then used to capture and code the hospice-qualifying diagnosis and the related secondary conditions and comorbidities on the claim form. This is not a physician-specific responsibility and is best done by a professional coder or staff member trained in hospice coding

Best Practices for Hospice Physicians

Work collaboratively with admission nurses to ensure that there are clear expectations of data/documentation needed for determination decisions

If possible, see new patients shortly after admission

Communicate clearly with team members about related/unrelated determinations

Make determination/coverage decisions at admission and as a part of IDG meetings when possible

Protocols/guides may be useful in the determination process but each decision must be based on patient-specific factors

Avoid “cookie-cutter” decisions

Be proactive in participating in the identification and resolution of any conflicts surrounding the appropriateness of certain interventions (e.g., parenteral antibiotics, specialist visits, transfusions, etc.) and DOCUMENT your determinations

Remember that relatedness refers to the terminal prognosis not solely the hospice-qualifying diagnosis; prognostication is a part of the practice of medicine